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Dermatology

Rash	Rosacea	Skin cancer	Leg Ulcers
Urticaria	Eczema	Infections	Sweating
Psoriasis	Benign lesions	Hair disorders	-----
Acne	Precancerous	Nail Disorders	-----

PLEASE NOTE: ALL REFERRALS ARE ROUTED THROUGH THE CLINICAL ASSESSMENT AND TREATMENT SERVICE UNLESS EMERGENCY OR 2 WEEK RULE

Primary Care

Dermatology Clinical Assessment Service

Rash	Diagnostic uncertainty	Consider scabies, eczema, drug rash etc and try empirical treatment. If no improvement routine referral Refer to PCT - Clinical assessment service (CAS) If erythrodermic urgent referral by phone to General Dermatology
	Urticaria /angioedema Local Guideline Urticaria Prodigy Guidance	No allergy testing available . Patients with acute episodes of urticaria and chronic urticaria for less than 6 months, manage in primary care. Exclude any associated diseases and tell patients to avoid all aspirin-, codeine-, and NSAID containing drugs. Treat with regular antihistamines (at double dose if necessary) .
		Severe chronic urticaria unresponsive to high dose antihistamines: Refer to PCT CAS - Dermatology Uticaria and a high ESR (erythrocyte sedimentation rate): exclusion of autoimmune disease and uticarial vasculitis.
	Psoriasis Local Guideline Psoriasis	Routine referral to PCT CAS - Dermatology • Diagnostic uncertainty • Failure of appropriately used topical treatment for a reasonable time (2-3 months) • Extensive disease, if unresponsive to initial therapy or difficult to self manage • Involvement of sites which are difficult to treat, if unresponsive to initial therapy • Need for systemic therapy, phototherapy (e.g. guttate psoriasis), day treatment or inpatient admission • Adverse reactions to topical treatment • Occupational disability or excessive time off work or school Urgent referral : • Acute unstable psorasis Emergency referral: • Generalised erythrodermic or generalised pustular psoriasis
	Acne Local Guideline Acne Clinical Evidence Acne Vulgaris	Mild/moderate acne not requiring Roaccutane, treat in Primary Care.
		If treatment fails - routine referral. Where patient shows indication for treatment for Roaccutane -routine referral: Severe nodulo-cystic acne – any age and either sex. Refer immediately but also start on high dose antibiotics, topical therapy and hormone therapy in women, Moderate acne that has failed to respond to prolonged courses of systemic antibiotic treatment in addition to topical treatment, and including hormone therapy for women. Mild to moderate acne in patients who have an extreme psychological reaction to their acne and have failed to respond to prolonged courses of systemic antibiotic treatment and added topical treatment, and including hormonal therapy in women.
	Rosacea	Treat in primary care with long course antibiotics and/or topical treatment.
	Rosacea	For severe, resistant rosacea, consider routine referral for roaccutane treatment
	Eczema in adults Local Guidelines Atopic Eczema in Adults	Routine referral where following is indicated: • Diagnosis is, or has become, uncertain • Eczema is severe and has not responded to appropriate therapy in primary care, particularly if excessive amounts of potent topical corticosteroids are being prescribed. • Eczema has become infected with bacteria (manifests as weeping, crusting or the development of pustules) and treatment with an oral antibiotic plus a topical corticosteroid has failed. • Eczema is giving rise to severe social or psychological problems; prompts for referral should include sleeplessness and time off work. • Management in primary care has not controlled the eczema satisfactorily • Contact dermatitis is suspected and confirmation requires patch testing Urgent referral: Severe infection with suspected herpes simplex (eczema herpeticum). Also use prompt antiviral treatment.
	Eczema in children (below 16yrs) Local Guidelines Atopic Eczema in Children	Routine referral where following is indicated: • Diagnosis is, or has become, uncertain • Eczema is severe and has not responded to appropriate therapy in primary care, particularly if excessive amounts of potent topical corticosteroids are being prescribed. • Eczema has become infected with bacteria (manifests as weeping, crusting or the development of pustules) and treatment with an oral antibiotic plus a topical corticosteroid has failed. • Eczema is giving rise to severe social or psychological problems; prompts for referral should include sleeplessness and loss of time at school. • Management in primary care has not controlled the eczema satisfactorily • Contact dermatitis is suspected and confirmation requires patch testing Urgent referral: Severe infection with suspected herpes simplex (eczema herpeticum). Also use prompt antiviral treatment.
	Patch testing Local Guideline Allergy Testing	For established cases of eczema where contact sensitivity is suspected, routine referral to establish allergic contact dermatitis through patch testing. The following indications suggest contact sensitivity: • Eyelid, face or perioral eczema as an isolated feature • Otitis externa • Hand dermatitis or foot dermatitis (first exclude psoriasis). • Eczema associated with venous ulcers • Unusual patterns of eczema, particularly asymmetrical patterns • If a patient with long standing endogenous eczema suddenly deteriorates, consider allergy to medicaments. • Female patients may have developed an allergic contact dermatitis to their cosmetics. • Contact allergic dermatitis is very common in occupationally-exposed groups Do not refer Urticaria for allergy testing. Do not refer children with a constitutional (usually atopic) pattern of eczema.
Infections	Bacterial	• Impetigo – treat with topical and/or oral antibiotics • Folliculitis – treat with skin antiseptics and/or oral antibiotics for 2-3 mths • Check nasal swab for staph. carriage • Swab other family members if appropriate Refer routine if severe and unresponsive to treatment.
	Viral	Swab as necessary and treat with anti-virals as appropriate. Don't forget secondary bacterial infection.
	Fungal	Take scrapings for mycology Treat topically for small areas but use systemic therapy for widespread or scattered areas. Fungal toenails do not necessarily need treatment
Hair disorders	Alopecia areata	Mild to moderate cases should be treated in primary care with reassurance, or topical steroid lotion for 1 month. Severe cases try a short course of oral steroids and refer.
	Generalised alopecia	Check Fbc, U/Es, LFTs, TFTs, Ferritin, Free Tetosterone. If normal suggest topical Minoxidil Refer if severe, sudden onset or significant psychological distress
	Hirsuitism	Mild to moderate cases should be treated in primary care. If failed refer to general dermatology clinic. If PCOS refer to Endocrine clinic
Nail Disorders	Fungal toenails do not necessarily need treatment	Always take clippings and scrapings before starting oral anti-fungal treatment. Examine rest of patient to exclude dermatosis as cause Treat Psoriasis nails with topical Dovonex or Tazorotene rubbed into nail bed daily for 3-6 months. If severe nail dystrophy affecting work refer routinely
Leg Ulcers	Venous leg ulcers	Routine referral to local Community Leg ulcer service. Routine referral for: • Suspected malignancy • Diagnostic uncertainty • Rapid deterioration of ulcers • Signs of contact dermatitis Refer to Vascular department • for arterial ulcers • Low ABPI Assessment for surgery
Sweating	Focal hyperhidrosis	If generalised hyperhidrosis (excessive sweating beyond physical needs) rather than localised (focal), routine referral to Endocrine clinic. If localised (focal) manage in primary care: • Treat with topical AIuminium salts, with emollient and corticosteroid if necessary. • If treatment is unsuccessful, routine referral

Skin condition	Core service treatment	Referral - Practices are encouraged to undertake minor surgery for small skin lesions. For practices unable to provide this service, or for lesions above and beyond their skill base, please refer PCT CAS - Dermatology
Benign lesions Local Guideline Warts	Viral Warts	Do not refer – Part of GMS contract additional service- Leave alone or use paints - could consider cryotherapy
	Molluscum Contagiosum	Do not refer-No treatment necessary.
	Skin tags	Do not refer – Part of GMS contract additional services- Treat only if problematic. Cosmetic removal not possible on the NHS
	Seborrhoeic Warts/ Keratoses	Do not refer – Part of GMS contract additional services. Treat using cryotherapy or curettage and cautery only when problematic. Cosmetic removal not possible on the NHS
	Pyogenic Granuloma	Suitable for Directed Enhanced Service - Curettage and cautery (histology essential)
	Benign Naevi/ Moles	Do not refer – Part of GMS contract additional services - Treat by shave and cautery. Cosmetic removal not possible on the NHS
	Spidernaevi /Cambell de Morgan Spots / Vascular Angiomata	Do not refer - Cosmetic. Treatment not possible on the NHS
	Epidermoid /Pilar (Sebacceous) Cysts	If problematic can be excised under the minor surgery directed enhanced service
	Lipoma	Cosmetic removal not possible on the NHS. Can be removed if causing significant problems. If problematic can be excised under the minor surgery directed enhanced service. If beyond the scope of the minor surgery service will be referred onto secondary care
	Dermatofibroma / Histiocytoma	Cosmetic removal not possible on the NHS - Problematic lesions can be removed under the minor surgery directed enhanced service
	Keratin Horn	Curettage and cautery (histology essential)- Suitable for Directed Enhanced Service
	Kerato-acanthoma	Suitable for Directed Enhanced Service
Precancerous lesions	Actinic Keratosis	Treatment with Solaraze or Efudix or cryotherapy or curettage and cautery
Precancerous lesions	Bowen's Disease	Do not refer – Part of GMS contract additional service- Treat with cryotherapy or curettage and cautery or Efudix
Skin cancer	Basal Cell Carcinoma (BCC) -superficial on the trunk	Suitable for Directed Enhanced Service Basal Cell Carcinoma Management Guidelines
	BCC – facial and/or nodular	Suitable for Directed Enhanced Service or Routine referral to PCT CAS - Dermatology
	Squamous Cell Carcinoma	Refer under the two week rule
	Melanoma	Refer under two week rule
NICE have made recommendations concerning the reorganisation of skin cancer services. The implications for primary care rest over the management of basal cell carcinoma and pre-malignant skin conditions. Find out more

Clinical diagnosis of melanoma

The seven-point checklist emphasizing a history of change in size, shape and colour of a pre-existing pigmented lesion is recommended for use .
Major features are:

change in size
irregular shape
irregular colour.

Minor features are:

largest diameter 7 mm or more
inflammation
oozing
change in sensation.

Lesions with any of the major features or three minor ones are suspicious of melanoma. Suspicious lesions should be referred. Where suspicious lesions are biopsied they should be removed completely and sent for histopathological examination.

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